Light & Fast

This week has been orientation at FACES clinic in Kisumu. I have the benefit of experiences from other residents who have been here, and the clinic has developed a standard approach to getting us up to speed.

On arrival, I dropped my things at the resident/student flat and headed to clinic for orientation. Probably something we should have done in our own clinics at home, I spent the first two days going through every step of the clinic’s intake process. First I welcomed patients and checked their appointments at registration, then checked vitals, sat in on HIV education and HIV adherence classes, shadowed nurses doing the initial assessment, and visited the pharmacy and laboratory. By the second or third day, I was sitting in with the clinical officers. It’s a challenge trying to learn as much as I can about the logistics and practicality of clinic flow, while avoiding being a burden (and needing translation frequently), and helping when I can. It was a flurry of introductions, swahili words, names and handshakes. The clinic visits run the gamut from routine stable patients, to HIV-associated complications, to other urgent issues like kidney infections and tuberculosis. Just figuring out which way is up has been exhausting. Reminds me of the first few days of internship at home. But even this small understanding of the many parts of this clinic has been useful.

Today at administrative day, we ran the numbers. There are roughly 5800 patients here at FACES, about half on ARVs.

The clinic itself has a nice newish two story building in Kisumu, with separate rooms for clinical officers and nurses, as well as the separate departments. Patients wait in the middle courtyard and the hallway. Upstairs are several data rooms with computers, offices for the medical officers and administrators, and the posters are lined with clinical research and case studies. There’s wireless internet, which has been a huge convenience for me and keeping in touch with home.

Going on safari is part of any classic Kenya trip, so I wanted to take advantage of my weekend arrival in Nairobi to get this out of the way. The Masai Mara is Kenya’s most popular wildlife park, located at its southern border, and the northern continuation of Tanzania’s Serengeti. I was fortunate enough to catch the tail end of the great migration of millions of wildebeest down south, when the predators are busy fattening up and the grass has been grazed down by the migrating horde (making it easier to see the animals). Funny how the grazing herds of impala, zebra, wildebeest and the like tend to blend into the landscape after awhile, our eyes peeled in search of the “big five” (lion, elephant, buffalo, leopard and rhino). We saw three.

The park also teems with tourists (despite low season), and the dozens of roving vans and SUVs can take away from the charm of being in the middle of the wild. So can the fact that cell phone coverage seems to be good here and there are a few radio towers cresting hilltops. But there is the advantage, in the midst of the hunt, that the many drivers and guides collude on their CB radios and plan out their search strategies for big game. The scene of 5 or 6 minibuses crowding around one or two slightly annoyed animals melts away at the amazement of seeing a lion or cheetah only feet away. The animals yawn. We ooh and ahh. You do have to wonder about human impact on these animals. But their numbers seem to be great, and there’s no shortage of food.

I went with a 3 day trip by Primetime Safaris, a value-oriented camping trip including transport, meals and a guide throughout the park. I was lucky enough to join a group of three Australians who have been volunteering outside of Kisumu. We camped overnight just outside the park, sleeping in stand-up, platformed tents with the sounds of hyena outside of our fences. The facilities were actually quite nice, with running water and toilets just short of Yosemite’s housekeeping units. The sunrises were awesome. Our cook was great. And the Masai guards, spears in hand, were a comfort after awhile.

It was my first time shooting wildlife, and my first time with a new 70-300mm telephoto lens. Really glad I had it. Here’s a sample. (took about an hour to upload) You can also go to my Flickr page. I’ll have more to come.

A young male lion with its wildebeest kill

I would never claim to understand the nuances and complexities of another country’s political system after a few days. Imagine even trying to sum up the political scene of the US. With Obama’s family being from the Kisumu area, and Bush (enough said), I’ve had a lot to share. Walking the line between apologism and optimism with all of the inquiring locals and travelers from other countries I’ve encountered. (Ask me later about my attempt at explaining the US health care system to some Australians)

But in Kenya, I can at least say that there is tremendous excitement around the upcoming general elections. Many (often tourist industry folks) I have encountered wait with optimism and a bit of anxiety about the possibility of violence, which seems to get a lot of press and has become less significant with each election since the 90s. From their point of view, the country’s growth has been good for them. And as I mentioned before, dips in the tourist industry and claims of “Asians fleeing the country” seem to be more rumor than anything. After all, I’m here, right? Hmm…

Every day the newspapers and news shows are filled with polling updates (or explaining what polls are), how many helicopters and 4×4s have been purchased by which political party to get their platforms out, and a lot of messaging and fingerpointing. Local rallies buzz in every poster-plastered town and village I have visited.

It’s fascinating. And not just because I’m watching a young democracy evolve. I don’t think we’ve figured it out yet either.

Conveyor Belts and Lines
Pretty smooth arrival despite the late night flight. Rushed through the line for Visas and Customs. Only to wait forever for baggage. Funny how traveling is filled with hurry up and waiting. Thirty long minutes staring at the conveyor belt at baggage claim, calculating all the places my bag might have been lost, shipped to another continent, or eaten by a gorilla (Remember that commercial?), but it finally came.

Checked into a campsite with cottages a short walk outside of downtown Nairobi, and slept soundly to the gentle patter of one of the first November storms coming down on my metal roof. It’s quaint, but next time I’ll get a place downtown.

Nairobi
Nairobi is what you might expect from a city that started as a British supply depot along the path to the Nile, soon becoming one of the major commercial centers in Africa. Skyscrapers, streets congested with taxis and buses, safari peddlers, cheap but slow internet connections, men and women in business suits. Nowhere near the same number of motorbikes as in Kampala. I haven’t read so many warnings to tourists about robbery or “Nairobbery” since I was in Rio, but so far so good.

Spent most of my time wandering around the city’s streets and public squares, and even visited the memorial site of the American Embassy bombing in 1998.

Plan from here is to see the town today, maybe check out the National Park this afternoon, and head to the Masai Mara tomorrow am for safari. Then head to Kisumu.

Part of any travel abroad is the trip itself…26 hours of it.

SFO ->CHICAGO (currently) ->London ->Nairobi.

HOTSPOTS
So I’ve finally decided to be one of those laptop-in-the-airport users. (I’m writing this at gate M10 in Chicago) My fantasies of traveling fast & light have really taken a hit with the expansion of technology and my love for gadgets. While I traveled to Uganda for a month with nothing but carry-ons, this time my laptop, plugs, palm pilot, dSLR camera and batteries pretty much take up an entire carry-on. I had to check bags gasp, leaving it to the luggage fairies (Jude?) to get my underwear to me safe and sound. What a painful night of packing. Next time, maybe just a good book and my stethoscope.

IS THERE A DOCTOR ON THE PLANE?
For the third time in the last year, I arose from my earplug slumber to the captain asking for a physician on the plane. This time a woman had become faint/?had a seizure? with a thready pulse and a slow heart rate after taking medicine for anxiety. To the rescue were two pediatricians and me. Especially since the flight attendant was exclaiming that we needed to land the plane. (Only 1 hour into my 26 hour, delicately balanced, three-leg flight, mind you). After laying her out on the floor for awhile, we had her walk it off with a couple liter of water. Reminded me a lot of working in the county ED.

trange, this good samaritan thing. MDs often feel an obligation, sometimes with anxiety, sometimes with pleasure that we can continuing being docs amidst our vacations. Not sure how the pediatricians took it, though.

Compliments of Worldmapper.com, here is the world, resized to reflect the magnitude of the problems.

HIV PREVALENCE (people aged 15-49 with HIV)

MALARIA PREVALENCE

WORLD DISTRIBUTION OF PHYSICIANS

WORLD DISTRIBUTION OF PUBLIC HEALTH SPENDING

It’s been three years, but I’m headed back to East Africa. This time to Kenya as a third year UCSF internal medicine resident. I’ll be working at the FACES clinic in Kisumu, Kenya.

From the FACES website:

“Family AIDS Care and Education Services (FACES) is an HIV/AIDS care and treatment program in Western Kenya and Nairobi. FACES is a collaboration between the Kenya Medical Research Institute (KEMRI) and the University of California, San Francisco (UCSF), funded through the US President’s Emergency Plan for AIDS Relief (PEPFAR).”

“AIDS deaths in Kenya have a profound and increasing societal and economic impact. Life expectancy in Kenya has dropped from 60 years in 1993 to 47 years due to the impact of HIV/AIDS1. The worst affected area is Western Kenya, where the prevalence is 15-40%.”

The rest of my Chile photos…

The rest of my Argentina photos

I stopped by the infectious disease institute at mulago hospital. this is one of the country’s premier hiv clinics. With a brand new shiny building funded by Pfizer, a major pharm company, they’re serving almost 10,000 patients now. They get 30-40 new patients daily, and they receive referrals for difficult cases across the country. They have beautiful facilities, on-site lab, x-ray, separate rooms for each provider and counselor, and plenty of capacity for drug trials and regional training. I was quite impressed. Of couse, it did lack the social model approach at ReachOut, which provides integrated social and community services in addition to clinical services. But in a country that currently estimates it has the capacity to provide ARV treatment to only one half the patients with AIDS, they’ll need to try and use all available models of care for delivering the necessary care.